What is the recommended treatment for iliotibial (IT) band syndrome?

Treatment of Iliotibial Band Syndrome

Conservative management with activity modification, iliotibial band stretching, and gluteus medius strengthening should be the first-line treatment for IT band syndrome, with most patients responding within 2-6 weeks. 1

Initial Conservative Management

Activity Modification and Rest

• Reduce running distance and modify training regimens immediately to allow inflammation to subside 1, 2
• Rest period of 2-6 weeks is typically required, with 44% achieving complete cure at 8 weeks and 91.7% at 6 months 3
• Avoid downhill running, track running in the same direction, and cambered surfaces that exacerbate lateral knee stress 2

Stretching Protocol

• Daily iliotibial band stretching is essential and forms the cornerstone of conservative therapy 1
• Focus on stretching the distal portion of the ITB where inflammation occurs 1
• Stretching should be performed multiple times daily for optimal results 1

Strengthening Exercises

• Gluteus medius strengthening is critical to address the underlying biomechanical dysfunction 1
• Hip abductor weakness contributes to increased ITB tension and should be corrected 1
• Progressive resistance exercises targeting hip stabilizers should be implemented 1

Adjunctive Therapies

Anti-inflammatory Medications

• NSAIDs can be used for pain management during the acute phase 1, 2
• However, evidence for significant benefit from NSAIDs alone is limited 4

Corticosteroid Injections

• Consider corticosteroid injections if visible swelling or pain with ambulation persists for more than 3 days after initiating conservative treatment 1
• Local cortisone injections have been used successfully in refractory cases 2
• This represents an escalation when initial conservative measures fail 1

Physical Therapy Modalities

• Deep friction massage has been studied but shows limited evidence for significant benefit 4
• Phonophoresis has been examined but lacks strong supporting evidence 4
• These modalities should not replace the core treatment of stretching and strengthening 4

Orthotic Intervention

• Orthoses may be beneficial in selected patients with biomechanical abnormalities 2
• Consider evaluation for foot mechanics and gait abnormalities 2

Surgical Management

Indications for Surgery

• Reserve surgical intervention for patients who fail conservative treatment after 6 months 3
• Surgery is appropriate for refractory cases with persistent symptoms despite comprehensive conservative therapy 1, 3

Surgical Options

• Arthroscopic release or excision of the pathologic distal portion of the iliotibial band shows 100% return to sport at 7 weeks to 3 months 3
• Bursectomy is an alternative surgical approach 3
• Arthroscopic techniques are more advanced and applicable to all patient types without absolute contraindications 5

Treatment Algorithm

1. Immediate phase (Days 1-3):

   • Stop aggravating activities
   • Begin ITB stretching and gluteus medius strengthening
   • Consider NSAIDs for pain control 1

2. Early phase (Days 4-21):

   • If swelling or pain with ambulation persists beyond 3 days, add corticosteroid injection 1
   • Continue stretching and strengthening program
   • Gradually modify training regimens 1, 2

3. Intermediate phase (Weeks 3-8):

   • Most patients (44%) achieve cure by 8 weeks with conservative management 3
   • Continue activity modification and exercise program
   • Consider orthotic evaluation if biomechanical issues identified 2

4. Extended phase (Months 3-6):

   • 91.7% cure rate achieved by 6 months with conservative treatment 3
   • Persistent symptoms warrant consideration of surgical consultation 1, 3

5. Surgical phase (After 6 months):

   • Arthroscopic release or excision for refractory cases 3
   • Expected return to sport at 7 weeks to 3 months post-operatively 3

Critical Pitfalls to Avoid

• Do not allow patients to continue running through pain, as this prolongs recovery and can lead to chronic symptoms lasting 2-6 months 2
• Do not rely solely on passive treatments like massage or phonophoresis without addressing the core issues of ITB flexibility and hip strength 4
• Do not rush to surgery before completing an adequate trial of conservative therapy, as most patients respond without surgical intervention 1, 3
• Ensure patients understand that active participation and compliance with activity modification is required for successful treatment 1